This SM program differs from others as the intervention is specific not only to their pathology (OA), but also to the joint affected (knee). Health professionals use their expertise to deliver information and education covering a wide spectrum of topics, while utilising the constructs of SM to enable participants to take control of their OA and to improve their self-efficacy.
The outcomes of this clinical intervention were a decrease in pain, improvement in quality of life, and an improvement in OA specific health status. These findings have a number of important implications for the management of patients with OA.
Patients with OA of the knee have identified pain and problems with daily activities as the most important problems associated with their condition [25]; hence the results of this study are well matched to their priorities. Moreover, the aim of this multidisciplinary SM program, to empower people to manage their condition [1], is consistent with the preference of patients to actively manage their own condition [25], and this approach is likely to have benefits in terms of both disease and financial outcomes.
Although SM in chronic illness has been studied extensively, most arthritis programs have been designed to be delivered by lay facilitators and are generic in their focus. This study targeted a specific site – the knee, and a single pathology (OA), while using health professionals to provide disease education, exercise advice in keeping with principles of joint protection, healthy life style options, and relevant information within the self-management construct to achieve these positive short and medium term results. As arthritis SM programs designed to be delivered by health professional leaders have rarely been conducted or evaluated, the results of this case series project are likely to be important in the future planning of SM programs.
We suggest that the improvements demonstrated in this study may be a result of a number of different factors. HP's provided modelling potential [26] with the orientation towards skills and expertise as well as support rather than a support and empathy orientated framework offered by lay leaders.
The delivery of specific information, education and direction in an easily digestible format allowed participants to understand the rational behind the theory included in the program [6]. Understanding the reason for the adoption of concepts in the program allowed participants to be self-motivated to change behaviour and therefore be more compliant long term [27]. An example of this is exercise. As participants increased their exercise level over the 8-week intervention period, most had a reduction of pain, improved wellbeing and feelings of accomplishment that motivated them to continue. What was previously negative reinforcement (pain) changed to become positive reinforcement (less pain and improved well being) [28].
Education in the correct use of medication and analgesia is linked to the point above. Fear of pain is often a greater limiter than pain itself – hence the fear of developing pain will inhibit people from attempting certain activities. Most people attending this QA program did not take analgesia to adequately control their pain. When participants felt confident that they could control their pain, they became more confident that aspect of their OA was manageable (and would exercise more, for example) [4]. Cognitive pain management was also part of the program syllabus and complemented pharmacological pain management.
Developing problem solving skills was encouraged. HP's skilled in musculoskeletal conditions offered advice or alternatives when hurdles were encountered so that participants achieved solutions rather than giving up, thereby improving SMART goal success and consequently improving self-efficacy [26]. Subsequent problems encountered were more likely to be problem solved rather than met with a defeatist attitude [6].
Using a self-management format to embrace HP skills, expertise and knowledge to deliver education in a format that participants could relate to in everyday life was hoped to improve self-efficacy in areas across the OA spectrum. It was thought that this would promote healthy life style and behaviour changes that would improve pain, physical function and quality of life.
Pain
In this study pain was measured in a number of ways, all demonstrating an improvement. A number of aspects of the self-management intervention may have contributed to the reduced pain levels reported by participants. Both aerobic and resistance exercise in a home-based exercise program have been shown to significantly reduce knee pain in-patients with OA [29, 30]. An important component of the OAK intervention is discussion on the formulation of a comprehensive home exercise program that incorporates strengthening, endurance, balance and flexibility components. Participants were not taken into a gym or given individual personal training; however they were encouraged to pursue that option independently.
The exercise component was not controlled and participants freely chose the type of exercise/s and the degree to which they would comply. By providing a number of exercise alternatives, it was hoped that exercise routines would become habitual by the end of the 6-week program. In accordance with self-management principles, participants were motivated to use their "library" of exercise choices when planning their weekly goals. The use of goal setting with participants promoted good adherence to the exercise program, as reported each week, but data regarding adherence were not collected for this study.
As well as exercise instruction and cognitive therapies, medication usage and therapeutic dosing principles in particular for analgesia were taught to encourage medication compliance and effective pain management. The average age of participants was 66 years and most had several co-morbidities requiring medication (Table 1). Many participants had an aversion to medications and delayed taking analgesia until their pain was acute and therefore more difficult to control. Pain management guidelines were discussed with the aim of determining patterns of pain. For example short term "around the clock" analgesia dosing for acute pain, or "as needed" analgesia for intermittent pain.
It is likely that the OAK intervention has facilitated better pain-coping skills that are important predictors of disability associated with OA. Previous studies have reported that catastrophizing and negative self-statements are associated with increased knee pain [31]. In the OAK intervention, participants were taught strategies for cognitive symptom management such as distraction, guided imagery, relaxation and thought challenging techniques that are considered to be important additional measures of pain management in people with OA [30, 32].
Health Status
Participants reported considerable improvements in physical function. Like pain, functional improvements were reflected by changes in a number of the parameters measured. It is generally accepted that the WOMAC questionnaire has greater specificity and consequently better responsiveness for people with OA [33], nonetheless, the SF-36 also reflected these changes.
Interpreting these results requires some understanding of the value patients place on improvements of this magnitude. Establishing this can be difficult. A number of methods, each with strengths and limitations, have been used but findings are not entirely consistent. Improvements of 9% to 10% in WOMAC scores in response to rofecoxib or ibuprofen were perceptible to patients with OA knee [34] when anchored against a patient global assessment of response to therapy. Changes observed in our study were generally more than twice this magnitude. On the other hand the 21.6% improvement in WOMAC function was somewhat less than 26%, the minimal level suggested by Tubach et al [35] as clinically important.
Expressed as effect sizes in standard deviation units the improvements in the WOMAC pain and SF-36 bodily pain domains would be considered moderate [23]. The consistency of this effect between different outcome tools supports the validity of the change. Effect sizes for the WOMAC functional domain and for the SF-36 mental health domains were slightly lower at 0.4. Notably these effect sizes are larger or comparable to the pooled effect sizes for general pain from systematic reviews of NSAID therapy [36] and aerobic walking [37] (0.33 and 0.52 respectively), although larger effects are often observed in uncontrolled studies. Further context for interpretation of the improvements we observed in quality of life measured by the SF-36 may be provided by considering the average decline of 2.1 points over 12 months reported in people with OA in this age group [15].
Limitations
The subjects who attended this quality assurance program were typical of those who attend self-management programs run by Arthritis WA. Over representation in the highest socio-economic group (Table 1) may affect the reproducibility of this program, however, the demographics of the area this program was conducted in are consistent with this attendance statistic. These results should be interpreted with caution as this limits the generalization to other socio-economic groups. Testing the OAK program with other socio-economic groups was outside the limitations of this QA program.
It is important to note that no control period or control group were available for comparison. Consequently, the clinical improvements observed in this cohort should be interpreted with caution. Despite this, improvements in response to this disease specific self-management program delivered by health professionals are encouraging and have interest. We therefore propose to further evaluate the benefits of this program using a more rigorous study design.
